AHIMA Comments on the Draft Supplemental Compliance Program Guidance for Hospitals

July 12, 2004

Office of Inspector General
Department of Health and Human Services
Attention: OIG-9-CPG
Room 5246
Cohen Building
330 Independence Avenue, SW
Washington, DC 20201

Dear Sir or Madam:

This letter is sent to provide comment from the American Health Information Management Association (AHIMA) on the draft supplemental compliance program guidance for hospitals developed by the Office of Inspector General (OIG), as published in the June 8, 2004 Federal Register . Complete and accurate medical record documentation and coding, ethical coding practices, consistency in medical coding and the use of medical coding standards in the United States are key issues for AHIMA, and it is with this in mind that we make the comments below.

AHIMA is a professional association representing more than 46,000 educated health information management (HIM) professionals who work throughout the healthcare industry. HIM professionals serve the healthcare industry and the public by managing, analyzing, and utilizing data vital for patient care and making it accessible to healthcare providers and appropriate researchers when it is needed most. AHIMA issues credentials in health information management, which includes coding. The following AHIMA credentials denote either entry-level or mastery-level coding expertise: Registered Health Information Administrator (RHIA); Registered Health Information Technician (RHIT); Certified Coding Specialist (CCS); Certified Coding Specialist-Physician based (CCS-P); and Certified Coding Associate (CCA).

In addition to these areas of coding expertise, some AHIMA members, due to their skills, experience, and training also serve as compliance officers in their respective organizations. Since the beginning of the emphasis on healthcare compliance AHIMA has sought to impart best practices and other resources to healthcare providers and compliance officers to ensure that they can meet the requirements and understand the guidance of your office.

As part of AHIMA's effort to ensure consistency in coding, we serve as a member of the Cooperating Parties, along with CMS, the Department of Health and Human Services' (HHS) National Center for

Health Statistics (NCHS), and the American Hospital Association (AHA). The Cooperating Parties oversee correct coding rules associated with the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM). Additionally, AHIMA participates in the American Medical Association's Current Procedural Terminology (CPT) maintenance process. AHIMA also participates in a variety of coding usage and standardization activities in the US and internationally.

Our desire for consistency in medical coding and data integrity leads AHIMA to advocate for US adoption and implementation of ICD-10-CM and ICD-10-PCS as quickly as possible. The increased detail and level of specificity in these coding systems improves both the accuracy the diagnosis and procedure codes reported on claims and the ability to effectively audit coding practices. The ambiguity of ICD-9-CM leads to increased numbers of coding errors and honest disagreements concerning the most appropriate codes for a given healthcare encounter.

Our comments focus on those areas that are of particular interest to our members. Unless otherwise noted, AHIMA generally agrees with the recommendations outlined in the Draft Supplemental Guidance. We appreciate that many of our previous recommendations have been incorporated. In particular, we commend the OIG for including the statement in the Internal Monitoring and Auditing section (page 32030) regarding the fact that coding and audit personnel should be independent and qualified, with the requisite certifications.

II: Fraud and Abuse Risk Areas (69FR32014)

II-A: Submission of Accurate Claims and Information (69FR32014)

The draft supplemental guidance states, “Underlying assumptions used in connection with claims submission should be reasoned, consistent, and appropriately documented, and hospitals should retain all relevant records reflecting their efforts to comply with Federal health care program requirements.” AHIMA is concerned with increases in reported instances of conflicts between the Centers for Medicare and Medicaid Services' (CMS') policies and provisions of the HIPAA regulations for electronic transactions and code sets. For example, in certain situations, CMS is requiring hospitals to report codes in a manner that conflicts with the ICD-9-CM Official Guidelines for Coding and Reporting. Since these guidelines were named as part of the ICD-9-CM code set standard in the HIPAA regulations, this type of conflict places hospitals in the untenable position of being non-compliant with either CMS policy or HIPAA requirements. Clearly, it is impossible for hospitals to comply with regulatory requirements in the submission of claims when these requirements conflict with each other.

AHIMA recommends that the OIG urge CMS to ensure any policies or instructions they issue are consistent with HIPAA and other regulatory requirements.

II-A1: Submission of Accurate Claims and Information – Outpatient Procedure Coding (69FR32015)

Failing to Follow CMS Instructions Regarding the Selection of Proper Evaluation and Management Codes

Footnote 20 refers to the evaluation and management (E/M) documentation guidelines used for physician services. Hospitals currently use the CPT E/M codes for reporting facility E/M services, however, they are not required to use the E/M documentation guidelines for physicians. Instead, CMS has allowed each facility to develop unique internal guidelines to report clinic and emergency department services provided by hospitals by mapping them to the levels of effort represented by the existing CPT ® codes.

In response to industry concerns that a lack of standardization would leave hospitals at risk for noncompliance with the HIPAA code set standards, CMS, in late 2002, called for “an independent expert panel” to develop consistent code definitions and guidelines to be used by the Medicare and Medicaid program for facility-based E/M services (67FR66792). AHIMA and the American Hospital Association convened an expert panel that developed a standard model for hospitals to report E/M services. The panel's final report was submitted to CMS in June 2003. To date, CMS has not yet published any recommendations regarding implementation of a standardized set of hospital guidelines. Therefore, hospitals are still currently required to develop their own internal guidelines for reporting E/M services.

AHIMA recommends that the language in the text of the supplemental guidance, which simply recommends that hospitals follow published CMS guidelines, be retained, but the footnote referencing E/M documentation guidelines for physician services should be deleted. AHIMA further recommends that the OIG urge CMS to move forward with adoption of a standardized system for reporting facility-based E/M services as soon as possible. A standardized system would ensure uniformity of reporting practices across facilities, improve the quality of E/M coding, and facilitate OIG and CMS reviews of E/M coding accuracy.

III: Hospital Compliance Program Effectiveness (69FR32028)

III-A: Code of Conduct (69FR32028)

AHIMA believes that a statement needs to be added indicating that licensed or certified healthcare professionals should adhere to the ethical standards established by their professional organizations. For example, AHIMA has a Code of Ethics that is binding on all individuals who hold an AHIMA credential. We also have a set of Standards of Ethical Coding that AHIMA-credentialed individuals are expected to abide by.

III-B4: Regular Review of Compliance Program Effectiveness – Appropriate Training and Education (69FR32029)

AHIMA recommends that a factor be added that addresses whether or not positions that create greater organizational legal exposure are filled with qualified individuals (those with appropriate educational background and training). For example, coding positions should be filled with individuals who possess the appropriate certification.

An emphasis on physician education, and physician participation in educational programs, should be added as a consideration when evaluating a compliance program's effectiveness.

In addition to the fact that trainers should be “qualified” to conduct compliance training, they should possess the appropriate certification for focused training (similar to the statement on page 32030 in the Auditing and Monitoring section of the supplemental guidance, which indicates that coding and audit personnel should have the requisite certifications). For example, individuals providing coding education should be certified coding professionals.


We appreciate the opportunity to comment on the draft supplemental compliance program guidance for hospitals. If AHIMA can provide any further information, or if there are any questions or concerns with regard to this letter and its recommendations, please contact either Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115 or sue.bowman@ahima.org, or myself at the numbers above or dan.rode@ahima.org.


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc: Sue Bowman, RHIA, CCS